Health inspection·November 20, 2024

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. California Code of Regulations, Title 22, Section 72315. Nursing Service – Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Code of Regulations, Title 22, Section 72527. Patient Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 10/9/2024, the California Department of Public Health (CDPH) conducted an abbreviated survey regarding resident abuse. As a result of the investigation, the CDPH determined the facility failed to protect Resident 1’s right to be free from physical abuse as indicated in the facility's policies and procedures (P&P) titled, "Abuse Prevention/Prohibition" and "Resident Rights". As a result, Resident 1 was subjected to physical abuse by Resident 2 and Resident 1 sustained an acute fracture of the left nasal bone. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1 on 1/18/2021 with diagnoses that included Alzheimer's disease with late onset, dementia, fracture of nasal bones, and initial encounter for closed fracture. A review of Resident 1's Minimum Data Set (MDS) dated 7/3/2024 indicated Resident 1 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 1 was independent with eating, oral hygiene, and toileting hygiene. The MDS indicated Resident 1 was independent for rolling left and right. A review of Resident 1's untimed Situation-Background-Assessment-Recommendation Communication (SBAR) form dated 10/3/2024 indicated on 10/3/2024 at 2 am, an unidentified Certified Nursing Assistant (CNA) reported to Licensed Vocational Nurse 5 (LVN 5) that Resident 1's nose was bleeding. The SBAR Communication Form indicated LVN 5 noted Resident 1 with bleeding nose and LVN 5 cleaned Resident 1's nose and applied ice pack. The SBAR Communication Form indicated Resident 1 was unable to recall what happened. The SBAR Communication Form indicated staff initiated neurological checks and frequent visual monitoring of Resident 1. A review of Resident 1's Progress Notes (PN) dated 10/3/2024, timed at 3:52 am indicated Resident 1's physician (MD 1) ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) for further evaluation. A review of Resident 1's GACH 1 Emergency Department Notes (EDN) dated 10/3/2024, timed at 7:32 am indicated Resident 1 came from Skilled Nursing Facility 1 (SNF1) and was hit on the face by another resident (Resident 2). The EDN indicated Resident 1 had an abrasion on Resident 1's chin. A review of Resident 1's GACH 1 Computed Tomography Scan result dated 10/3/2024, timed at 8:17 am indicated Resident 1 had nasal soft tissue swelling and an acute fracture of the left nasal bone without significant displacement. A review of Resident 1's GACH 1 EDN dated 10/3/2024, timed at 2:24 pm indicated Resident 1 had no other complaints or findings on examination. The EDN indicated Resident 1 did not require further intervention and was stable for discharge back to SNF 1. A review of Resident 2's AR indicated the facility admitted Resident 2 on 4/5/2024 with diagnoses that included type 2 diabetes mellitus, paranoid personality disorder and unspecified psychosis. A review of Resident 2's MDS dated 7/11/2024 indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 required setup or clean-up assistance for upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance for rolling left and right. A review of Resident 2's untimed SBAR form dated 10/3/2024 indicated on 10/3/2024, at 2 am, Resident 2 was involved in a physical altercation with another resident (Resident 1). The SBAR form indicated Resident 2 stated Resident 2's roommate (Resident 1) was standing too close to him (Resident 2), and Resident 2 felt his roommate (Resident 1) was going to hit him (Resident 2). The SBAR form indicated Resident 2 struck Resident 1 in the nose. During a telephone interview on 10/10/2024 at 3 pm with LVN 5, LVN 5 stated Resident 1 came out of Resident 1's room with a bloody nose on 10/3/2024. LVN 5 stated Resident 1 and Resident 2 were roommates. LVN 5 stated Resident 2 stated Resident 2 struck Resident 1 in the face. LVN 5 stated Resident 2 stated Resident 2 did that because Resident 1 was standing too close to Resident 2. LVN 5 stated Resident 2 thought Resident 1 was going to hit Resident 2. During a telephone interview on 10/10/2024 at 3:44 pm with Registered Nurse 1 (RN 1), RN 1 stated LVN 5 informed RN 1 that Resident 1's nose was bleeding on 10/3/2024. RN 1 stated RN 1 asked Resident 2 what happened. RN 1 stated Resident 2 stated Resident 1 was too close to Resident 2. RN 1 stated Resident 2 stated Resident 2 hit Resident 1 in the face with Resident 2's fist. During an interview on 10/10/2024 at 4:50 pm with the facility’s Administrator (ADM), the ADM stated residents needed to be free from abuse. The ADM stated residents must feel safe mentally, physically, and emotionally in the facility. The ADM stated the facility staff needed to ensure the residents were safe in the facility. The ADM stated a physical altercation occurred between Residents 1 and 2. The ADM stated to prevent a physical altercation between residents, the facility staff needed to ensure the roommates were compatible and provide enough close supervision of residents. The ADM stated facility staff needed to be trained to identify certain behaviors so they could prevent an altercation from happening. A review of the facility's P&P titled, "Abuse Prevention/Prohibition," revised November 2018 indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems to promote an environment free from abuse and mistreatment. A review of the facility's P&P titled, "Resident Rights," revised February 2021, indicated federal and state laws guarantee basic rights to all residents of this facility. The P&P indicated these rights included the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation. The facility failed to protect Resident 1’s right to be free from physical abuse as indicated in the facility's P&P titled, "Abuse Prevention/Prohibition" and "Resident Rights". As a result, Resident 1 was subjected to physical abuse by Resident 2 and Resident 1 sustained an acute fracture of the left nasal bone. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.